Healthcare Provider Details

I. General information

NPI: 1598920977
Provider Name (Legal Business Name): PRESCRIPTIVE WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2008
Last Update Date: 12/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 W 177TH ST STE 3F
HAZEL CREST IL
60429-2197
US

IV. Provider business mailing address

3330 W 177TH ST STE 3F
HAZEL CREST IL
60429-2197
US

V. Phone/Fax

Practice location:
  • Phone: 773-404-0160
  • Fax:
Mailing address:
  • Phone: 773-404-0160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number036106614
License Number StateIL

VIII. Authorized Official

Name: DR. CARLA WATSON
Title or Position: MD
Credential: MD
Phone: 773-404-0160